32-34 NHS - Crazy maze phase

There is a deceptively simple question at the heart of the English NHS – and one that frequently baffles pharma clients at HSJ Information: who is actually in charge?

For much of its history, the answer, while never perfectly clear, followed a recognisable chain of command. Ministers set direction, NHS England managed the system, commissioners commissioned and providers delivered.

For those seeking to work with the NHS, including pharma, the task was to understand that hierarchy and engage with it.

In the shadow of the NHS’ 10 year plan and the power carousel it set in motion, that clarity is fading.

In its place is something more diffuse: a system of shared, negotiated authority in which power depends on context. And while recent reforms promise simplification, they are also reshaping where control really sits.

It is that dull sounding but ineffably important word: governance. The practical reality that determines who makes decisions, and ultimately how, where and whether medicines are adopted.

If you are trying to find the right people to engage, this is a commercially vital reality. This article is about stakeholder mapping it all.

During the 2010s, the organising idea of the NHS was distance from government. NHS England operated at arm’s length, providing a buffer between political priorities and operational delivery. That settlement has now shifted.

The direction of travel is back towards central control. This month, NHS England was officially absorbed into the Department of Health and Social Care, which is now more directly engaged in operational priorities. National bodies are taking a firmer grip on performance and finance. This reflects a political reality: when waiting lists rise or cancer targets are missed, accountability ultimately sits with ministers.

The result is a system that is more directly steered from the centre, with less tolerance for local variation. But that does not mean control is straightforward. Instead, it is being exercised through new layers.

If there is a tier that best captures this rather cloudy sense of operational authority, it is NHS regions.

Often overlooked, regional teams have become the de facto performance managers of the system. They sit between the centre and local systems, overseeing both providers and Integrated Care Boards, monitoring delivery and intervening where performance falters.

This matters to pharma because performance management is power over your customers. Regions may not commission services or hold budgets in the traditional sense, but they increasingly shape which priorities dominate locally, where attention and resource are directed, and how strictly national expectations are enforced.

In effect, regions form a shadow hierarchy, less visible than national bodies but highly influential in determining system behaviour.

For companies seeking to understand adoption and uptake, this layer is easy to miss and increasingly important.

Integrated Care Boards were designed to be the linchpin of a more collaborative NHS: system leaders bringing organisations together; shifting care upstream and improving population health.

That ambition remains. But the conditions in which ICBs operate have changed significantly.

Their responsibilities are still extensive: delivering financial balance across systems; planning and redesigning services; forging links with local government; implementing national priorities such as elective recovery and cancer performance overseeing primary care developing neighbourhood health models, and managing medicines optimisation and formularies.

Taken together, this is a formidable agenda. Yet ICBs are being asked to deliver it while facing tightening running cost envelopes, headcount reductions, and a shifting role within the system.

They need pharma’s immediate help to get a grip on therapy areas, prevention, and more efficient patient pathways.

Alongside these expectations, ICBs are dealing with significant internal churn.

Headcount reductions are being driven by cost-saving requirements. At the same time, staff turnover is high, as roles evolve, teams are restructured and experienced leaders move on. Recruitment is often slower, and vacancies are not always backfilled.

Crucially, this is not limited to ICBs that are formally merging or clustering. Even relatively stable systems are seeing portfolios reshaped, teams reorganised and institutional memory eroded.

This has direct implications for delivery. A system that depends heavily on relationships between commissioners, providers, primary care and local authorities relies on continuity. When teams are in flux, those relationships must constantly be rebuilt.

At the very moment ICBs are expected to provide system leadership, many are losing the people who understand how the system actually works. So tracking who can make a difference becomes extra challenging.

This creates a deeper structural tension. ICBs are accountable for outcomes, finance and integration. But many of the levers required to deliver those outcomes sit elsewhere.

Providers control service delivery and workforce. Regions oversee performance and can intervene. National bodies set priorities and funding constraints.

ICBs therefore operate in a space where responsibility is clear, but authority is shared.

They are expected to think like system leaders, act like commissioners and deliver like operators, while increasingly being resourced like coordinators. You could say their role is stretching rather than shrinking.

For all the structural change, one fact remains constant: NHS Trusts are where care is actually delivered.

They employ the workforce, run the services and make the operational decisions that determine patient experience. No system architecture alters that fundamental reality.

However, Trusts are now subject to tighter oversight than in previous years. Regional performance management, combined with national expectations, means autonomy is more constrained. Financial pressures further limit room for manoeuvre.

The result is a system in which Trusts hold operational power, regions hold performance authority and ICBs attempt to align the two.

Alongside these shifts, policy continues to emphasise care closer to home. Primary Care Networks and neighbourhood health models are positioned as the future of prevention and integration.

The ambition is clear. What the structures will eventually look like is less so. Originally the grand plan was to have 150 new ‘Neighbourhood Health Centres’ by 2030. Sounds cool, right? Shiny new buildings that can treat all manner of complaints closer to home.

And yet: HSJ recently ran a story revealing how, in order to be designated a ‘Neighbourhood Health Centre’, you just need to be a GP practice with a community team. Isn’t that pretty much all of them?

It is fair to say that the neighbourhood health agenda is a work in progress. PCNs do not hold budgets or statutory authority. ICBs remain responsible for primary care performance. The contractual process for how neighbourhood health providers will be financed is still being worked out.

Fortunately for pharma, our Audience Access team at HSJ has been closely monitoring developments on the ground and gathering cutting-edge data on where the new wave of providers will be and who will run them. But until the whole sector goes properly live on a national footing, this is a watch this space.

In the NHS, structure tells only part of the story. Funding and incentives are often the more reliable guide to where power lies.

For the pharmaceutical sector, this layered model is particularly visible.

Access to medicines is shaped by national clinical and cost-effectiveness frameworks, ICB level affordability decisions, local formulary choices and then clinical judgement at the point of care.

No single actor is in control. Instead, decisions emerge from interaction between layers, each with different priorities.

Formularies illustrate this clearly. While national guidance sets direction, ICBs interpret it in the context of budgets; committees determine inclusion, and clinicians ultimately prescribe.

In practice, this means that variation persists, and not as a failure of the system, but as a function of how it is designed.

For pharma, the implication is clear: there is no longer a single ‘customer’ in the NHS.

Engagement strategies built around a single decision-making centre are increasingly misaligned with reality. Success depends more on understanding how different layers interact in specific systems.

ICBs remain pivotal, particularly for formulary decisions, pathway design and medicines optimisation. But they are operating under pressure, with stretched teams and competing priorities. Engagement must reflect this: targeted; relevant and timed to align with system pressures.

Regions, while less visible, are increasingly influential. Their role in performance management means that therapies aligned to regional priorities, whether in cancer, elective recovery, or prevention, are more likely to gain traction.

At the same time, place and neighbourhood structures are emerging as interesting future customers, particularly in more mature systems. Here, earlier engagement in pathway design may be possible, but the landscape is uneven and evolving.

One consequence of this uneven model is that understanding the NHS has become as much a data challenge as a structural one.

I have been hawking NHS national organisational charts for 20 years and I know now that it is not enough. What matters is who actually influences decisions within systems, how stable those stakeholders are and how priorities are shifting over time.

In a context of high churn, particularly within ICBs, static stakeholder maps quickly become outdated. Roles evolve, responsibilities shift and informal influence can be as important as formal authority.

The same is increasingly true at neighbourhood level. As systems develop new models of care, customer landscapes are becoming more granular, more dynamic and harder to track.

Our pharma clients for data and CRM are already responding to this reality, building increasingly detailed, continuously updated pictures of stakeholders, decision-making forums, and local priorities.

The ability to track these changes in near real time is becoming a prerequisite for effective engagement rather than a competitive advantage.

For pharma, this creates a new kind of access challenge, depending less on engaging a single decision-maker and more on understanding how decisions are distributed, identifying where influence actually sits within systems and aligning with priorities at multiple levels simultaneously.

The organisations that succeed will be those that can track stakeholder change as it happens, understand local system dynamics, not just national policy, and engage across layers, from system leadership to neighbourhood delivery.

Because in today’s NHS, access is no longer about knocking on the right door, but knowing which doors matter, how they connect and when multiple people have the key. I think I have stretched this metaphor enough.

The return of the centre

Stealthy rise of NHS regions

ICBs – central to everything

Shrinking and shifting workforce

Responsibility without full control

Neighbourhood health

Funding, incentives and medicines

What this means for pharma

A data problem

Power, visibility, challenges